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ARTIGO ARTICLE 15

Paradigm shift, metamorphosis of medical , and the rise of

Transição paradigmática, metamorfose da ética médica e emergência da bioética

José Luiz Telles de Almeida 1 Fermin Roland Schramm 1

1 Departamento de Ciências Abstract Both the increasing incorporation of medical technology and new social demands Sociais, Escola Nacional (including those for ) beginning in the 1960s have brought about significant changes de Saúde Pública, Fundação Oswaldo Cruz. in medical practice. This situation has in turn sparked a growth in the philosophical debate over Rua Leopoldo Bulhões 1480, problems pertaining to ethical practice. These issues no longer find answers in the Hippocratic 9o andar, Rio de Janeiro, RJ ethical model. The authors believe that the crisis in Hippocratic ethics could be described as a 21041-210, Brasil. period of paradigm shift in which a new set of values appears to be emerging. Beginning with the bioethics movement, the authors expound on the different ethical applied to med- ical practice and conclude that is the most appropriate approach for solving the new moral dilemma imposed on clinical practice. Key words Bioethics; ;

Resumo A crescente incorporação de tecnologia médica e as novas demandas sociais, inclusive de saúde, que tiveram início nos anos 60, impuseram importantes transformações na prática médica. Tal situação tem estimulado crescente debate filosófico em torno de problemas de ética prática que não mais encontram respostas no âmbito do modelo ético hipocrático. Para os au- tores, a crise da ética hipocrática poderia ser caracterizada como um período de transição para- digmática em que se estaria formando um novo conjunto de valores. A partir do movimento da bioética, os autores apresentam as diferentes teorias éticas aplicadas à prática médica, concluin- do que a abordagem principialista seria mais adequada à resolução dos novos dilemas morais postos à prática clínica. Palavras-chave Bioética; Ética Médica; Medicina

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Introduction According to Mori, the most relevant prob- lems in contemporary bioethics are located at What common ground can one find between this second level of analysis, since “the greatest the advent of the contraceptive pill and the per- disagreement in this area concerns the princi- sonal computer revolution, between ples themselves” (Mori, 1990:199). and civil movements, or be- The current article presents the discussion tween the increased level of schooling in the US on the process of change in references for med- population and the rights movement? ical ethics based on the theoretical contribu- All these phenomena have been observed tions of bioethics, according to the model pro- more frequently in the last three decades, main- posed by Pellegrino (1995), characterizing this ly in the United States, and have had either di- stage as a ‘metamorphosis of medical ethics’. rect or indirect influence on health care in gen- eral and medical practice in particular. New so- cial demands have been raised, whereby tradi- Pertinence of the debate tionally passive and obedient patients have been replaced gradually by health care con- Changes in medical practice caused by both the sumers, who in are active and aware growing incorporation of technology and new of their rights. We have reached a point where social demands appear to suggest a special mo- medicine at the turn of the century is said to be ment in the of contemporary medicine. focused less on its role of curing human suffer- However, can we really say that we are experi- ing and more on promoting ‘customer satisfac- encing a crisis period in the prevailing medical tion’, thus launching a new era of the medicine model and the emergence of a new biomedical of desires (Pellegrino, 1979). paradigm? In the course of this article we seek However, this transition has not been free to respond affirmatively to this question, con- of conflict and uncertainty. After all, we are ex- sidering the emergence of bioethics as a strong periencing the age of the end of certainties, indication of just such a situation. even in the field of ‘hard’ sciences like physics The term paradigm was introduced into (Prigogine, 1996). As in any paradigm shift, and by Kuhn in his essay The Structure this is true for the transition from a traditional of Scientific Revolutions, published in 1962, medical care model to a new one (still not fully shedding great light on the history of sciences. consolidated), ethical tensions tend to mount. According to Kuhn, paradigms are “universally The emergence of bioethics in the context acknowledged scientific achievements which, of clinical practice has enriched the debate on for some period of time, provide model prob- changes in medical ethics, because any prob- lems and solutions for a community of practi- lem in bioethics, as suggested by Mori (1990), tioners of a given science”(Kuhn, 1996:13). In can be the object of at least two different levels such periods of scientific development, which of analysis. he calls ‘normal science’, the conceptual frame- At the first level, one seeks to identify the work of a discipline (i.e., its paradigm) remains most adequate solution for a ‘particular case’, invariable and scientists are occupied in solv- assuming that there is agreement as to the rel- ing its problems based on the unchallenged evant problems involved in the problem at reference of the prevailing paradigm. hand. Many of the quotidian problems faced Yet no matter how long these periods may by in clinical practice are solved on last, they are not eternal, since from time to the basis of traditional (Hippocratic) medical time scientists produce results that contrast ethics. It is thus a matter of properly applying with consolidated theories, thus leading to the in keeping with the specific situ- problems that cannot be solved within the pre- ation. Yet the difficulty arises when one at- vailing paradigm. However, Kuhn emphasizes tempts to assess the different psychological that such problems, or ‘anomalies’, do not and social conditions experienced by physi- necessarily lead to a paradigm shift. Yet as cians and patients, keeping in mind that clini- such anomalies accumulate, “normal science cal knowledge does not reflect certainties, but soon becomes disoriented. And when this oc- merely probabilities. It is thus necessary to pro- curs – that is, when members of a profession ceed to a second level of analysis. can no longer avoid the anomalies that subvert The second level seeks to specify the very existing tradition in scientific practice – extra- principles applied to a given case and forces ordinary investigation begins that finally leads one to adopt a broader analytical perspective, the profession to a new set of commitments, a since the search for and specification of ethical new basis for the practice of science” (Kuhn, principles define the very nature of social life. 1996:25).

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Santos (1989, 1994), in turn, in analyzing Such determination in curing diseases and the crisis of modernity and its epistemological prolonging human life through advances in and societal paradigms, introduces the term medical knowledge meant that beginning in paradigm, characterized “by the reconceptual- the 1970s there emerged new problems that ization of existing science as a new science, the failed to find adequate answers within the Hip- outline of which is barely visible” (Santos, 1989: pocratic ethical model. In the past, when physi- 148). In fact, a transition period means that the cians could do little for their patients, there prevailing model or paradigm has failed to pro- were no major ethical concerns beyond those vide answers to given problems, although its prescribed by Hippocratic tradition. However, replacement is not fully established. Thus we ethical ‘issues’ could no longer be ignored feel that the use of the paradigm concept sheds when it became possible to transplant vital or- light on the current stage of philosophical re- gans from one person to another, diagnose flection concerning medical practice. congenital anomalies in utero, and prolong the Such paradigm changes in the sciences were lives of incurable patients. also observed in late 18th-century medicine. As As Wulff et al. stress: “The medical profes- suggested by Foucault, during that period med- sion finally realizes that clinical practice is not ical research began to correlate diseases and merely an applied natural science, but that clin- their signs and symptoms with anatomical le- ical decisions always entail judgments. sions and to define them as “a system of analyt- The result of this new awareness is that contem- ical classes in which the element of pathological porary clinicians speak not only of cure and sur- decomposition was the principle for generaliz- vival, but also of quality of life for their pa- ing morbid species” (Foucault, 1994:150). From tients”(Wulff et al., 1995:20). that point on, a conflict was established be- The emerging ethical questions in medical tween two figures in medical know-how: classi- practice indeed appear to indicate that the ficatory medicine and anatomo-pathological traditional medical paradigm has been chal- medicine. It is interesting to note that precisely lenged on the basis of a philosophical reflec- during this period of medicine the philosophi- tion that we see as a moment of paradigmatic cal problems were the center of attention for instability, justifying the pertinence of this de- medical debate (Wulff et al., 1995:18). As Kuhn bate on the process of metamorphosis in med- explains: “The emergence of new theories is gen- ical ethics. erally preceded by a period of professional inse- In the opinion of Pellegrino (1995), this per- curity, since it requires the large-scale destruc- tinence is justified by the following: tion of paradigms and major changes in the 1) Medical ethics, like medicine, is a syn- problems and techniques of normal science.” thesis of and practice, and the quest for (Kuhn, 1996:95) solutions to practical moral decision-making Recourse to philosophy would thus be the problems is thus totally dependent on the con- means to overcome such a state of insecurity, ceptual framework used to define what is right since it “makes us perceive our ignorance and and wrong, or bad. creates the desire to overcome uncertainty” 2) Physicians should acknowledge that (Chauí, 1996:90). and philosophical theories have Once this state of insecurity has been over- exerted a powerful influence on the change in come, the emerging paradigm adds more and medical ethics; nonetheless, the task of ethical more scientists and establishes a new period analysis and reflection should not be reserved of normal science. In medicine, this new phase exclusively for philosophers or jurists. was characterized by technical and scientific 3) Physicians should be aware of the philo- progress, which was increasingly successful in sophical arguments employed by their own pursuing and establishing the cure for dis- colleagues when they defend drastic changes eases as its main purpose. Throughout this pe- in medical tradition. riod of ‘normal science’, ethical issues were Of the issues listed by the author, the one limited to the sphere of Hippocratic medical pertaining to practical moral decision-making ethics. problems may be most deserving of our atten- Callahan points out that one of the values tion. After all, medicine has been seen as a sci- that emerged was the moral and social demand ence that grows on the basis of isolated or pure for unlimited medical progress, establishing facts, and one that is thus in a neutral position the “as if in a sacred military campaign, to vis-à-vis value issues (Guillén, 1995: 192). always march ahead of the frontiers of medicine In fact, science, on the one hand, consti- and dominate the disease surrounding us at the tutes itself as a field that builds pertinent and moment”(Callahan, 1994:76). true knowledge, i.e., establishes provable or

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refutable enunciates. Axiological or ethical is- The 1st stage, or the period sues, on the other hand, pertain to the search of tranquillity in Hippocratic ethics for what can be judged as good according to a given time and . As Schramm empha- The point of departure for the metamorphosis sizes, “the principal practical consequence of was the oath credited to Hippocrates (some this is that we must distinguish between scien- 2,500 years ago) and the deontological or pro- tific knowledge stricto senso, i.e., the formula- cedural books from the Corpus Hippocraticum. tion of refutable hypotheses (and the discovery In fact, historical evidence suggests that the of ‘truths’ about what such knowledge is) and its anthology called Corpus Hippocraticum was technical applications” (Schramm, 1997:208). collated in the early third century BC under an However, the development of science and order from Ptolomy. The compilers used limit- in particular that of life and health sciences in ed critical spirit in their selection work, lump- recent decades has established a new scientific ing a mass of excerpts, abstracts, and fragments configuration. Science has literally become together with legitimate masterpieces (Olivei- techno-science, that is, “a kind of knowledge ra, 1981:75). which is increasingly a rational and operational On the other hand, the in- way of knowing” (Schramm, 1997:209). cluded a major portion of the genuine moral What implications does this change have for principles and can be organized into four parts, ethics? Increasingly independent from the ab- according to its specific contents: solute principles shared by and in part 1) Introduction, in which the in- by the major universalist , ethics has vokes the Greek gods Apollo, Aesculapius, become more applied or practical (Singer, 1994). Hygeia, and Panacea as witnesses to his oath; Thus, as Schramm highlights, “ethics and 2) Chapter 1, in which the physician ac- science, although methodologically distinguish- cepts the commitment, together with his mas- able, can also be seen as pragmatically linked” ter, to teach the art of medicine, free of cost, to (Schramm, 1997:209). the latter’s children and other disciples taking This new techno-scientific configuration the oath in the future; raises challenges for medical practice based on 3) Chapter 2, including the moral principles the Hippocratic tradition. Pellegrino (1995) prohibiting abortion, , surgery, and thus uses the term ‘metamorphosis of medical sexual relations with patients; and ethics’, a historical process consisting of four 4) Conclusion, reaffirming the commitment periods or stages, according to the author: to the terms of the oath, having as one’s recom- 1st stage – begun by Hippocrates and his pense the esteem of all men, or the opposite, disciples and marked by a long period of tran- should the principles be violated (Guillén, 1989: quillity in which the Hippocratic tradition (en- 45-71). riched over the centuries by Stoicism and The principles contained in the Hippocrat- monotheistic religious traditions) was seen as ic oath were accepted uncritically and venerat- a given, a belief prevailing until the 1960s; ed until the mid-18th century, when there was 2nd stage – characterized as a stage of an initial critical reading of Hippocrates’ writ- philosophical investigation during which moral ings by Emile Littrè, in 1861 (Littrè, 1861). theories based on principles began to trans- Until then, the principles were considered form medical ethics (began in the 1960s and sacred, not only because they were ‘invio- prevailed until the mid-1980s); lable’, but also because the physician was con- 3rd stage – called anti-principlism, i.e., the sidered a kind of lay priest, acting in favor of moral theories that compete with each other nature and the gods to cure the patient under and have challenged the primacy of principles; his care. this stage, dating to the early 1980s, is now The ‘sacred’ principles of generosity, dedi- reaching its end; cation, and impartiality, according to Schramm, 4th stage – began in the 1990s, character- constituted the underpinnings providing legiti- ized as a stage of crisis in which conceptual macy to the medical art “in the form of an oath conflicts and skepticism in moral philosophy linking medical know-how to a feeling of empa- are placing in check the notion of universal, thy and the principle of responsible , for medicine. making the ‘art of curing’ acceptable to the We consider the author’s classification a pólis, i.e., publicly” (Schramm, 1994:326). good working outline for organizing the dis- The decision-making method over the cussion on the process of change observed in course of these 2,500 years consisted of judg- medical ethics, as well as for situating the emer- ing whether a given conduct was in keeping gence of bioethics in the health care scenario. with Hippocratic principles.

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Pellegrino (1995) points out that neither erty; b) such rights were individual, and their ancient nor modern philosophers devoted achievement depended exclusively on individ- their attention to a systematic ethical justifica- ual initiative; and, c) the rights proposed by tion of the physician-patient relationship on Locke imposed on ourselves, thus hav- which to base physicians’ decisions and pa- ing a positive value. As stressed by Guillén, “In tients’ well-being. Neither was there any signif- the final analysis, our ultimate duty to ourselves icant change during this period as medical is to lead our lives to perfection and to achieve ethics entered into contact with the main : the most ‘positive’ duty one could monotheistic religious traditions. imagine” (Guillén, 1994:32). Among the latter, played an The medical profession was thus cloaked in outstanding role in shaping Western thinking. legal in the context of constituting In early Christian , diseases were viewed the modern state, based on legally defined as divine punishment or instruments to test a competence, thus meaning that the profession follower’s faith, thus denying the natural ori- should possess an objectively outlined set of gins of illnesses. The dichotomy between the duties and services, the allocation of the neces- art of curing founded on the Hippocratic tradi- sary powers for their realization, and the close tion and Christian religion was first challenged definition of admissible sanctions and the pre- by the ideas introduced under the theological supposition of their application in such cases doctrine of Saint Augustine of Tagaste (340-430 (Guillén, 1989:86). AD), reconciling Christianity with classic cul- The Hippocratic ethical tradition did not ture, drawing it progressively closer to lay phi- have any of its principles challenged until the losophy and thus allowing for a conjunction of mid-1960s. From then on doubts began to ‘science’ and religion (Antunes, 1991:49-50). emerge concerning the traditional moral un- The physician’s moral authority, based on derpinnings of society as a whole and medicine Hippocratic values, which persisted through- in particular, thus opening the way for critical out the Middle Ages (reinforced by Christiani- questioning. ty), was gradually replaced by legal authority beginning in the 16th century. This legal au- thority, with the modern state as its paradig- The 2nd stage, or the emergence matic framework, was based on the concept of of bioethics and principlism legally defined competence. Guillén (1994) emphasizes that from the The questioning of medical ethics was partially mid-17th century to the present at least three due to the widespread upheaval in moral val- different types of were devel- ues in the United States throughout the 1960s. oped: As a decade of mass demonstrations and social ‘1st generation’ or civil and political rights; transformations, it was characterized mainly ‘2nd generation’ or economic, social, and by a higher educational level for the American cultural rights; people, expansion of democratic participation ‘3rd generation’ or ecological rights and led by the civil rights and feminist movements, those of future generations. as well as consumer activism, a decline in All three types of rights bear a close rela- shared community values, increased emphasis tionship to health and constitute the basis for on different ethnic origins, and widespread classic ethical principles. distrust towards and institutions in The first rights, or those of the first genera- general. In addition, the very meaning of medi- tion, began with the publication of John Locke’s cine underwent changes through the special- Two Treatises on Civil Government in 1690 ization, fragmentation, institutionalization, and (apud Guillén, 1994), laying the groundwork depersonalization of health care. The number for the modern theory of human rights. Ac- and complexity of problems in medical ethics cording to Locke, in the natural state, when hu- also grew as medical technology raised new man beings had still not established the social moral challenges to traditional values. pact with which civilized life began, life was The demand to legalize abortion led by the regulated by a primary law, i.e., natural law, feminist movement in the 1960s was one of the making all human beings their own masters. moments of greatest social polarization in the The importance of Locke’s work was based on United States, contrary to some European coun- the following: a) for the first time a table of civil tries, where the debate was limited to the po- and political rights had been drafted, including litical and legal spheres. In the United States, the right to life, the , the right to the of abortion came under discus- freedom of , and the right to prop- sion, since physicians themselves often had

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trouble judging certain clinical cases (Mori, had also demonstrated how abuses were com- 1994:334). mitted almost exclusively against socially vul- In addition, this same period also wit- nerable individuals such as prison inmates, the nessed growing concern over possible abuses diseased, the mentally ill, soldiers, and mem- by the power of science over the lives of indi- bers of ethnic minorities, thereby breaching viduals, mainly after the work of Katz was pub- another principle of bioethics, that of lished in 1972. An American psychiatrist, Jay (Beecher, 1966). Katz performed a historical work-up of bio- It was also in the 1960s and 70s that major medical sciences with regard to abuses in sci- technological innovations occurred in the bio- entific experimentation on human beings (Katz, medical field which raised further major ethi- 1972). For the first time there was a public ex- cal challenges. The following are some of the posé of cases that were to become paradigmat- more important examples: ic in the awareness of the need to place limits a) the work of James Watson and Francis on scientific practice. Three cases received the Crick, who discovered the structure of genetic most attention: material, leading to the development of special 1) A research project on 600 African Ameri- techniques allowing for the precise mapping of can men from Tuskegee, Alabama, from 1932 to each gene and serving as the basis for the most 1972, came to be known as the ‘bad blood’ ambitious research project undertaken by hu- case. The researchers withheld information and mankind, the Human Genome Project (HGP), proper available treatment (penicillin) from the hub of debate involving a number of seri- 399 carriers of the disease in order to study its ous ethical issues pertaining to all of society long-term effects. The principle of informed (Thomasma & Kushner, 1996); , which had already been formulated in b) the first heart transplant, performed in the Nuremberg Declaration in 1947, was fla- 1967 by Christian Barnard, sparking a debate grantly breached, compounding what was also over the origin of the organ, the donor’s explic- an explicit case of racial and social prejudice. it desire (or lack thereof) to donate, and the The experiment was not interrupted until 1973, very concept of ; and after being exposed a year before on the front c) the problems raised by the impossibility page of the New York Times. of making dialysis universally accessible. This 2) Another case involved the injection of last issue became emblematic of the dilemma live liver cancer cells in 1964 in 22 elderly pa- in choosing between who could have access to tients at the Jewish Chronic Disease Hospital in new technology for chronic hemodialysis and Brooklyn, New York. In this case the physicians who would be excluded from it. This occurred also believed that they could perform any kind in Seattle in 1962, and the difficult choice led of research as long as it was (supposedly) to to the formation of a small committee, most of benefit scientific progress, but in fact the pa- whom were non-physicians. The criteria cho- tients were not sufficiently and adequately in- sen for selecting patients most in need of he- formed so as to provide their informed con- modialysis caused considerable controversy to sent. The physicians were declared guilty of the extent that they were not limited to clinical breach of , fraud, and mal- aspects. Thus, “Only after much protest and nu- practice. merous demands, a federal program was ap- 3) Approximately 700 to 800 severely retard- proved in 1973 making dialysis accessible to ed children at the for everyone, based exclusively on clinical criteria” the Retarded from 1956 to 1970 were intention- (Berlinguer, 1996:93). ally infected with hepatitis virus. In this context of widely renewed interest in Katz’ work had broad repercussions on ethical phenomena in general and the gradual public opinion in the United States in the early yet widespread introduction of knowledge and 1970s and helped fuel the bioethics movement. techniques in the biomedical sciences, the term In 1966, Harvard Medical School professor bioethics was coined by oncologist Van Renss- Henry K. Beecher had already published an ar- laer Potter in 1970 and publicized in this book ticle showing that in North American clinical Bioethics: Bridge to the Future in the year 1971. practice, abuses were common against the According to Potter, bioethics was a ‘new sci- health and life of patients submitted to scien- ence’ aimed at guiding human beings in their tific research, despite formal recognition of the relationship to nature. It was to be a kind of principles of non-maleficence, , new ‘scientific ethics’ aimed at guaranteeing and , aimed at protecting the human survival and quality of life, focusing on subjects of scientific research (Nuremberg development and population problems, em- Code, 1947, apud Annas & Grodin, 1992). He bracing the emerging problems in the field of

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health. According to Potter, biology, which is ing with the range of obligations physicians currently extending its horizons beyond the have towards their ‘professional world’: pa- traditional descriptive sphere, should also in- tients, patients’ families, society in general, clude norms and values in its own field of in- professional colleagues, the state (Segre, 1995: vestigation. 27). , meanwhile, derives Potter’s professional experience as oncolo- from the of and gist was crucial to his stance, since he realized , comprising a set of ethical that the links between the various types of can- doctrines that measure the goodness or of cers and deteriorating environmental condi- acts based on their beneficial or maleficent tions in general (but especially in the work- consequences (Guisán, 1992:277). These two place) were beyond the measures traditionally philosophical schools exerted great influence employed by the sphere of medicine. It was on ethical theories as applied to health. thus necessary to develop a ‘global ethics’ in- The four principles scheme is attractive for cluding humankind’s relationship to the envi- clinical practice for the following reasons: 1) It ronment (Reich, 1995:21). provides quite specific orientation for the clini- Yet the term bioethics took on a different cal act. 2) It offers an organized way of framing meaning from that originally proposed by an ethical problem, analogous to clinical work- Potter. This change was linked to the creation up leading to diagnosis or that of a therapeutic of the Kennedy Institute for the Study of Hu- strategy. 3) It allows for a direct approach to man Reproduction and Bioethics in 1971, certain problems causing great disagreement, where bioethics was not considered a ‘scien- like abortion, euthanasia, and a number of oth- tific ethics’, but rather ethics applied to a new er problems where consensus seemed impos- field of study, the medical and biological field sible (Pellegrino, 1995:26). (Mori, 1994:34). The principles of non-maleficence and During this period, Beauchamp & Childress beneficence were in keeping with the Hippo- (1994) adapted the theory of prima facie prin- cratic obligations of always acting in such a ciples developed by Ross. Sir David Ross had way as to avoid causing harm (primum non no- published a famous book, The Right and the cere) and to take the patient’s well-being into Good, in the 1930s, contending that moral life account (bonum facere). On the other hand, had grown out of given principles that were the principles of and justice were basic and self-evident for all of Western soci- new, and in a certain sense they appeared to ety (Ross, 1930). Yet these principles were not run against traditional ethics, based on med- mandatory or absolute; rather, they should be ical and authoritarianism. considered prima facie, i.e., admitting excep- The autonomy principle has only been ac- tions under specific circumstances. cepted by physicians in recent years because it Ross also established a hierarchy amongst is essential for free, informed consent and is al- the principles of justice, non-maleficence, and so in keeping with the North American individ- beneficence. In his opinion, the principle of ualist tradition, with its emphasis on non-maleficence took priority over that of and self-determination. In the opinion of Pel- beneficence (Guillén, 1995).The reason was legrino (1995), it was one of the most powerful that all individuals, in principle, had the oblig- driving social forces in the metamorphosis of ation to not harm other individuals, while the medical ethics. obligation to do somebody good was limited to Of the four principles, that of justice is the certain professions, like medicine. one that most departs from traditional med- By adapting Ross’ principles, Beauchamp & ical ethics. It entered the scenario first through Childress (1994) acknowledged that there were physicians’ forensic duties and more recently a number of difficulties to overcome in order to due to disparities in the distribution of health reach a consensus on the most important is- care. sues in ethics. While Beauchamp & Childress viewed the The prima facie principles chosen were the four principles as not having an a priori hierar- following: non-maleficence, beneficence, au- chy, Guillén (1995) proposed to divide them in- tonomy, and justice. These four fundamental to two levels: the private sphere or level, includ- moral ideas share the merit of being compati- ing the principles of beneficence and autono- ble with the main theoretical currents of deon- my, and the public sphere, including the princi- tology and consequentialism. Deontology (from ples of justice and non-maleficence. According the Greek root deontos, meaning ‘duty’ and lo- to the author, public duties take priority over gos, or ‘study’) was the basis for the develop- private ones, since public duties are part of the ment of medical deontology, a discipline deal- “classic procedural principle, long present in the

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legal and ethical tradition, which affirms the underlying theories and worse, without an ade- superiority of the common good over the private quate unifying theory to coordinate and inte- in case of conflict between them”(Guillén, grate these separate, albeit essential, features of 1995:197). morality”(Clouser, 1995:224). Still, we do not view this hierarchical divi- The authors thus propose, as an alternative sion between public and private duties as the to principlism, a common morality, “with its central issue in the debate over ‘principlism’, rules and ideals, which in turn are grounded in which is usually translated into Portuguese as aspects of human nature. As such, morality must principalismo, but which we propose to trans- be understood to be a rational, impartial, and late as principialismo (with an i as indicated), public system that is incumbent on everyone” to avoid the derivation from principal and to (Clouser, 1995:219). Based on common morali- mark the derivation from princípios, since the ty, the authors propose that a study of the four principles were originally proposed to be morality experienced in the daily lives of indi- applied not automatically, but rather to be ad- viduals could constitute the outline for the justed to each given case, that is, within their moral domain. This domain should thus be- specific context. come the object of study and theoretical foun- Since the principles are prima facie, trans- dations. They emphasize that the central thrust gression of any one of them must be justified. of professional ethics includes the various in- Beauchamp & Childress proposed four basic terpretations of general moral rules and that conditions for justifying transgression of a the building of such theoretical foundations principle or prima facie obligation a) the moral should contribute to improve these same object on which it is based should be realistic; ethics (Clouser, 1995:235). b) no morally preferable alternative should be We view the common morality espoused by available; c) one should seek the lesser trans- Clouser & Gert as a pretense of returning to a gression; and d) the agent should take mea- stage prior to principlism. We do not feel it is sures to minimize the effects of the transgres- possible to define a universal moral theory ca- sion (Beauchamp & Childress, 1994:34). pable of establishing consensus in a context of The four principles theory was the target of plurality in which tolerance is weighed against objections and attempts to overcome it based authoritarianism, the latter being incompati- on new theoretical contributions. This flourish ble with democratic . of new theories dealing with the ethical dilem- Another line of thought in bioethics has mas in medical practice would be the third been developed by Hugo Tristram Engelhardt stage in the metamorphosis of medical ethics. Jr., espousing a radical understanding of ethics in the secular context of Western societies. His most important work, The Foundations of The 3rd Stage, or the Period Bioethics, published for the first time in 1986, of Antiprinciplism was considered a libertarian paradigm (Neves, 1996:12). Inspired by the philosophical tradi- This period was characterized by critiques of tion of North American (in the de- the four principles theory, or so-called princi- fense of rights and individual property), Engel- plism (Clouser & Gert, 1990). It launched the hardt Jr. placed the principle of autonomy in debate over the theoretical contributions need- the first order of priority. His proposals not on- ed to base medical decisions in an increasingly ly allow one to justify actions resulting from the complex scenario of health care work. Despite patient’s expression of , but also help the debate not being resolved, we review the justify the body as individual property, thus main bioethical schools questioning the pro- providing legitimacy for the sale of organs and posals by Beauchamp & Childress in order to blood. The controversy arising out of interpre- allow us to take a critical stance towards this tations by other authors may have led him in stage in the metamorphosis of medical ethics. the 2nd edition (Engelhardt Jr., 1996) to refor- According to Clouser & Gert, the four prin- mulate the priority ascribed to the principle of ciples lack a solid theoretical base, observing autonomy, replacing it with the principle of that the principles emerged as ad hoc con- permission, through free and informed con- structs “It looks as if each principle simply fo- sent. In the author’s words: “Because secular cuses on the key aspect of some leading theory of morality cannot provide a canonical vision of ethics: justice from Rawls, consequences from the good or a canonical content-full account of Mill, autonomy from Kant, and non-malefi- proper action, the principle of permission is the cence from Gert. Thus they represent some his- cardinal source of moral authority” (Engelhardt torically important emphases, but without the Jr., 1996:288).

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Free and informed consent, the basis for decisions on any a priori principles to orient the principle of autonomy, has been consid- action. In their opinion, the theoretical frame- ered the cause of the greatest changes occur- work, i.e., ethical theory, is built on cases and ring in the physician-patient relationship. remodeled from time to time (Jonsen, 1996: The individualist focus taken by Engelhardt 251). Thus, the paradigmatic characteristics Jr. contrasted with the model of the theory of of each case must be examined, establishing ‘’ (Virtue-Based Normative Ethics) devel- comparisons and analogies with other cases. oped by Pellegrino & Thomasma (1988). Based In our view, amongst the various alterna- on the Greek, Aristotelian tradition of an ethics tives presented thus far, principlism provides of virtue, the authors turn the focus on the the best conditions for decision-making in agent, especially health care professionals, biomedical practice. The four principles ap- while taking care to fully integrate the patient proach is not intended to dictate absolute into the diagnostic and therapeutic decision- rules or norms for moral conduct. On the con- making process. trary, it identifies basic prima facie principles Pellegrino (1995) contends that medical that should be weighed for each specific situa- theory developed under three phenomena in tion. According to the authors defending prin- relation to cure: 1) the disease; 2) the health ciplism, such principles do not aim to elimi- professional’s action; and 3) the act of cure. nate conflicts, amongst other reasons because (Pellegrino, 1995) The first phenomenon means it appears difficult to find a moral guideline that when people experience physical and psy- that would anticipate all possible situations chological symptoms, they believe that they (Beauchamp, 1994:9) The principles should need help. In this context of vulnerability, physi- thus be seen as a set of guidelines to aid deci- cians and nurses ask the patient, “How can I sion-making, making flexible, tolerant ethical help you?”. Implicit in this question is the com- professional stances possible. mitment that such professionals have the nec- Pellegrino adds that despite the limits of essary knowledge to help and cure the patient. principlism, the principles will probably not The act of curing, in turn, directs knowledge disappear, since: a) every ethical system has and techniques in such a way as to help the principles, at least implicitly; b) any theory pre- particular patient. It is the telos in the relation- senting itself as an alternative to principlism ship between the health professional and the will have other severe limitations; c) the need patient, i.e., restoration of health and contain- for and usefulness of principles become clearer ment or cure of the disease. to the extent that we attempt to apply other What are the of health profession- theories to concrete cases; and d) the principles als? Despite admitting difficulty in defining a are not intrinsically incompatible with other ‘good professional’, the author lists some es- theories (Pellegrino, 1995:29). Besides, we would sential virtues for proper professional practice: add, there is nothing to prevent other principles a) faithfulness to the deposited in them; from being added to the list of four, if this b) benevolence; c) compassion; d) freedom should prove necessary in the future. from self-interest; e) intellectual honesty; and f) justice and prudence (Pellegrino, 1995). The author’s analytical perspective is par- The 4th Stage, or the period of crisis: ticularly pertinent for cases of mercantilism or the immediate future refusal to treat certain cases (AIDS, highly con- tagious diseases, various types of discrimina- This fourth stage is characterized by a strong tion, etc.). The unresolved issue is how to dose of nihilism and skepticism in contempo- awaken the value of virtue in health profes- rary philosophy and ethics. The position re- sionals in situations that are often adverse to sults from a very specific reading of authors . like Nietzsche, Heidegger, Rorty, and Derrida The care model proposed by Gilligan (1982) by Pellegrino, according to whom they have in compares the care value of expression, which common the notion that one single truth is the author contends is typically female, with merely an illusion. that of justice, expressly male, and proposes to One could thus say that there is a kind of employ it as the main thrust for the develop- radical relativism leading one to think that ment of professional ethics in health. medical ethics is a Western product incompati- Another idea that merits attention is the ca- ble with other cultures as pertains to the issue suistic model proposed by Albert Jonsen and of autonomy. Stephen Toulmin in 1988. The authors recom- However, Pellegrino himself casts a relative mend a case-by-case analysis, without basing light on this reading of our contemporary reali-

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ty as applied to the discussion of medical ethics, contingent discipline, i.e., required by concrete since the universal nature of the disease/cure dilemmas demanding analysis and solution phenomenon and medicine’s medium- and (Kottow, 1995:81). long-term objectives lead to hope for reach- The current article stresses that the bioethics ing a more solid basis for the principles, rules, movement is not limited to changes in medical virtues, and of medical ethics practice stemming from the growing incorpo- than in any other ethical domain. ration of technology or to use a more specific Viewed from this perspective, clinical term, “biotechnosciences” (Schramm, 1996:114). bioethics is one of the hopeful signs. The field We emphasize that one of the fundamental fac- is still not fully defined, but it proposes to ap- tors in the process of change was the wave of proach the realities of moral options faced by mass social mobilizations in the 1960s, placing health professionals in their daily work: “It is society in a participant, decision-making posi- not at all clear where the continuing metamor- tion rather than in a mere spectator’s role vis- phosis of medical ethics will lead us in future à-vis the changes for which it is both subject years, given the problematic current state of and object. Participation by the social body in philosophy and ethics itself (...) A continuing di- the bioethics movement requires both a deep- alogue with the moral philosophers is a requi- ening and radicalization of participant democ- site for physicians not to lose the benefits deriv- racy and broader access to formal and informal ing from a rigorous and critical analysis of their educational means. Brazil’s social indicators, own decisions. Medical ethics is too old and es- especially those related to education (Almeida, sential to the lives of physicians, patients, and 1996), suggest that much remains to be done to society at large and should not be abandoned to achieve effective social participation in the de- either the vicissitudes of philosophical styles or bate over bioethical problems. the unfounded assertions of physicians” (Pelle- In the sphere of medical ethics, the princi- grino, 1995:32-33). plist approach appears to be the most ade- quate for solving the dilemmas posed by clini- cal practice, since it serves as a guideline given Conclusions the impossibility of shaping a unitarian, uni- versally accepted ethical theory in plural, de- In the contemporary , techno- mocratic societies. logical changes are accompanied by new so- In addition, the necessarily multidiscipli- cial and cultural attitudes making the individ- nary and transdisciplinary nature of bioethics ual the main decision-making authority on is- has allowed it to include other approaches, en- sues relating to life-style values and personal riching medical ethics and broadening its ana- goals. Thus one of modern society’s funda- lytical horizons. mental characteristics is a plurality of ideas Finally, it is our belief that the bioethical and values, leading educated citizens and debate applied to clinical practice must be clients and providers of services to reach tacit deepened as an urgent condition for medical agreements over the risks and benefits provid- ethics in particular and health-related ethics in ed by given services, especially health services. general in shaping health services in keeping As emphasized by Cherry, “The fragmented with Brazilian society’s real aspirations and character of modern contemporary society leads possibilities. us to re-examine the institutional roles and In short, the emergence of bioethics in the norms of medical practice” (Cherry, 1996:367). field of biomedical sciences demands that so- The emergence of bioethics in this context ciety in general and the health professions in sparks a discussion of ethics for the practical particular engage in a deep reflection on the field of the relationship between biomedical new ethical dilemmas which in the final analy- science and society. As pointed out quite ap- sis will define the kind of society we build for propriately by Kottow, bioethics was born as a the future.

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